Healthcare Provider Details

I. General information

NPI: 1083188122
Provider Name (Legal Business Name): ANGELA M ORVIS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4555 W SCHROEDER DR
BROWN DEER WI
53223-1475
US

IV. Provider business mailing address

34700 VALLEY RD
OCONOMOWOC WI
53066-4599
US

V. Phone/Fax

Practice location:
  • Phone: 800-767-4411
  • Fax: 414-797-0804
Mailing address:
  • Phone: 800-767-4411
  • Fax: 262-646-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3628-57
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3628-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: